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r - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t <br /> OFFICE USE: ' 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I _ <br /> THIS PERMIT EXPIRES t YEAR FROri DATE ISSUED Date Issued .1_L-7-;76 ' <br /> (Complete Ia Triplicate) <br /> Application is hereby made to the San Joaquia Local Health District for a permit to construct <br /> and/or install the cork herein described. This application is made in compliance with San Joaquin <br /> w County Ordinance No. 1862 and the Rule: and Regulations of the San J��aquin Local Health District. <br /> /i.r ^.ENSIJS TRACT <br /> JOB ADDRESS/LOCATION 4229 R_ I,niS?__i$e_�� 4 •— <br /> Owner's Name <br /> Address 14222 F,. Loii s <br /> se -7e City Ron <br /> = ry License # 200794 Phone-948-88i7 <br /> Contractor's Name _3;;;7j tpr <br /> TYP�� OF WORK (Che c1 }; NEW WELL / / DEEPEN / / RECONDITION 1 i DESTRUCTION 1-7 <br /> PUMP "INSTALLATION 07 <br /> PUMP REPAIR / / PUMP R'JPLACF.MENT ]I <br /> Other / / <br /> DISTANCE TO NEAREEr: SEPTIC TANK SEWER LINES PIT PRIVY �, <br /> n SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ��'•R <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL —.- PUBLIC DOMESTYC WELL � <br /> INTENDED USE TYPE OF WELL rONSTRUCTION SPkCIFICATION3 • <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> x - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/p <br /> Lblic Driven Gauge of Casing <br /> . Irrigation Gravel Pack Depth of Grout. Seal <br /> CRotary Type o£ Grout <br /> Cathodic Protection <br /> Disposal Other Other ir.£ormation <br /> Geophysical Surface Seal Installed By: <br /> PUM}' INSTALLATION; Contractor liLli ;ex G. �1Oack &: Son <br /> Type of Pump Subs ers3ble H.P. ! 4 <br /> PUMP REPLACEMENT: .x( State Work Done lest:=l7.ed n-9w pip - <br /> PUMP .REPAI%: I I State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to c::mpl.y with all laws and regulations of the San Joaquin Local Health Dictrict <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR <br /> A GROUT INS. 6, T <br /> PRIOR TO GROUTING AND ,i FINAL INSPECTION. TITLE EG� <br /> SIGNED '�"'- <br /> DRAW P'' FLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE <br /> A°PLICATION ACCXPTED BY /i' f <br /> ADDITIONAL COMW-NTS: T PHA I F AI INSPECTI <br /> PHASE' II GROUT INSPE':."TION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> we 3 76 2K <br /> r' <br /> rd i � <br /> E H 1426 Rev. 1-74 Lu <br />